Healthcare Provider Details

I. General information

NPI: 1356907422
Provider Name (Legal Business Name): CRYSTAL SUE EDWARDS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL SUE VAUGHAN

II. Dates (important events)

Enumeration Date: 05/14/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N ST
ANCHORAGE AK
99501-3285
US

IV. Provider business mailing address

PO BOX 870192
WASILLA AK
99687-0192
US

V. Phone/Fax

Practice location:
  • Phone: 785-320-1708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number216209
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number151869
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5100
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: